【作者】 丁道宝；

【导师】 柴铁劬；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 背景：肩周炎又称漏肩风、肩凝症、冻结肩或五十肩,是中老年人的一种常见病,多发生在50岁左右,女性多于男性。临床以肩部疼痛,关节活动受限,甚至局部肌肉萎缩为其主要临床表现,主要症状是肩关节周围痛,有时放射到上臂,夜间疼痛明显,肩关节活动受限,影响洗脸、背手、梳头和穿衣等,给患者的日常生活带来极大的不便。目前,西医疗法主要为消炎止痛,虽然取效迅速,但副作用大,疗效难以持久,不能解决根本问题,而非药物疗法(针灸、推拿)被广泛应用于对本病的治疗,并取得较好效果。中医认为,肩周炎属“痹症”范畴,为风寒湿三气杂至,阻滞经脉,影响机体气血运行,筋脉肌骨失于濡养,不通则痛,不荣则痛,进而引发肩周的慢性反复性疼痛。针灸疗法是传统中医学的重要组成部分之一,具有无毒副作用,操作简易,疗效确凿的特点。应用针灸疗法治疗肩周炎的研究报道逐年增多,但目前研究存在以下几个方面的问题：(1)肩周炎的临床疗效标准尚欠规范化,由于临床疗效标准的不统一给疗效评定带来很大困难；(2)设置对照多系自身对照,而不同疗法进行对照则较少见；(3)临床研究以简单疗效比较为主,观察不够系统规范,无法体现出不同疗法的优越性：(4)单一疗法较多,综合疗法较少。肩三针是肩髃、肩髎、肩前的合称。肩周炎的疼痛大多以经脉循行区域为特点。而肩三针的取穴是对肩周炎多经症状的高度概括治疗,加以三针齐刺,故临床取之效专而力宏。临床单独应用肩三针和推拿疗法治疗肩周炎均取得了良好疗效,为进一步发挥传统中医综合疗法的优越性,对肩三针结合推拿治疗肩周炎的临床疗效进行进一步研究,以期对此作出客观科学的评价,进一步提高应用中医传统疗法治疗肩周炎的临床疗效,为临床治疗提供依据。目的：采用随机对照临床研究,通过对运用肩三针结合推拿疗法治疗肩周炎患者的临床疗效、肩关节疼痛程度、肩关节活动功能评分及肩关节活动功能(肩外展、肩前屈、指椎间距、指耳间距)的疗效进行观察评价,综合判定肩三针结合推拿疗法治疗肩周炎的临床疗效。以期对此作出客观科学的评价,并为多种疗法配合使用治疗肩周炎提供新的思路和理论依据。方法：将符合纳入标准的门诊肩周炎患者90例按随机数字表随机平均分成3组：针刺组、推拿组、针推结合组,针刺组采用肩三针治疗、推拿组采用推拿治疗、针推结合组采用肩三针结合推拿治疗。分别于治疗前后对患者临床疗效、肩关节疼痛变化程度、肩关节功能评分、肩关节活动变化程度进行检测,然后进行统计分析。(1)第一组(针刺组)：采用肩三针疗法治疗。①取穴：肩髃、肩髎、肩前；②针具：天协牌28号2.0寸一次性使用的不锈钢针,苏州天协针灸医疗器械有限公司；③操作方法：患者取坐位,暴露患侧肩部,医者用75%的酒精棉球将局部进行常规消毒后。取穴采用先左后右,先上后下的原则,术者双手持28号2.0寸的不锈钢针毫针,与皮肤呈90度角快速刺入约1～1.5寸,得气后施行平补平泻法,留针约30分钟,留针期间行针1次。(2)第二组(推拿组)：采用推拿手法治疗。①松筋活血：患者取坐位,肩部自然下垂放松,术者站立于患者患侧,用拇指指腹或掌根部在痛点上按揉。手法由轻到重,反复操作约5min；②疏通经络：体位承上,选取肩井、肩髃、肩髎、肩前、天宗等穴,每穴按掐1min左右。③动摇关节：体位承上,术者一手与病人患手相握,用力抖动,且边抖边作肩关节展收、屈伸等运动。另一手搭于患侧肩部,作肩部揉搓,动摇关节幅度由小到大,切忌暴力强摇关节。摇毕,双手卡住上肢、肩部,自上而下用搓法、揉法疏理筋肉；④弹筋拨络：患者取坐位,术者于肱二头肌长头键、短头肌、或冈上肌键等处,用拇指和食、中指相对提拿弹拨,用力由轻渐重,起到解除粘连的作用。(3)第三组(针推结合组)：采用肩三针结合推拿治疗。针刺取穴、操作及推拿操作分别同针刺组、推拿组。(4)以上各组均有运动康复配合,嘱患者日常生活注意保暖、避风寒,治疗期间注意保护肩关节。以上治疗1次/天,十次为一疗程,共治疗2疗程后进行评定各组临床疗效、肩关节疼痛变化程度、肩关节功能评分、肩关节活动变化程度。结果：1.针推结合组的疗效优于针刺组及推拿组。(P<0.01),针刺组与推拿组临床疗效没有明显差异(P>0.05)。2.治疗前,肩部疼痛程度两两秩和检验比较,P>0.05,差异无显著性意义；治疗后肩部疼痛程度第三组与第一组、第二组比较有显著性差异(P<0.01)；第一组与第二组比较没有差异(P>0.05)。3.治疗前,肩周炎关节功能分级的两两秩和检验比较,差异均无显著性意义(P>0.05)；经治疗后,肩周炎关节功能分级的两两秩和检验比较,第三组与第一组、第二组的差异有显著性意义(P<0.01),第一组与第二组比较无显著性差异(P>0.05)。4.治疗前,肩周炎关节活动功能(肩外展、肩前屈、指椎间距、指耳间距)两两秩和检验比较,差异均无显著性意义(P>0.05)；经治疗后,肩周炎关节活动范围的两两秩和检验比较,第三组与第一组、第二组的差异有显著性意义(P<0.01),第一组与第二组比较无显著性差异(P>0.05)。结论：1.针推结合治疗肩周炎的疗效具有较好的临床意义,为多种疗法配合使用治疗肩周炎提供新的思路和理论依据。2.针推结合治疗组治疗肩周炎的疗效明显优于针刺组和推拿组。3.针刺组与推拿组治疗肩周炎不具有显著差异。更多还原

【Abstract】 Background:Periarthritis of shoulder joint was known as Leak shoulder wind、Shoulder coagulation disorder Frozen shoulder or 50 shoulders。It is a common diseases that age of onset was about 50, female more than male. Its main clinical symptoms are the pain, confined activity and partial muscle atrophy of shoulder. The pain of shoulder always expressed among shoulder joint, sometimes radiating arm, exacerbating in night. The diseases make the life of patients unconvenient.Present, antiphlogistic and analgesic is the main method of western medicine. Although getting effect quickly, its effect cannt be permanent and its side effect is big. So the method cannt solve the problems fundamentality. Non-drug treatment(acupuncture, massage) are widly applicated in periarthritis of shoulder joint and get great effect.Periarthritis of shoulder joint was consider as "Bi syndrome" in Traditional Chinese medicine.The mechanism of chronic repeatable pain of shoulder joint is that qi and xue cannt provide the jinmai and musculoskeletal, after the wind cold dampness blocked the meridian, and impacted the running of qi and xue. Acupuncture is the important component of Traditional Chinese medicine. Its characteristics are non-side effect, simply operating and definite effect. Although the reports on the acupuncture treatments of Periarthritis of shoulder joint are more and more, there are some problems in the studies:(1)the clinical effect standard of periarthritis of shoulder joint is not normalization, and then it brings more difficults on efficacy evaluation. (2) It is rare that comparing many therapies. (3)the observation that simple efficacy comparing is not system standardization and cannt embody the different advantages of methods. (4)the studies on single therapy are more than Combined therapy.The third-shoulder points method is the JIANYU, JIANLIAO, JIANQIAN. The pain of periarthritis of shoulder joint always advents in the region of meridian travelling course. The three points of the methods hightly summarized the many meridians symptoms, so the clinical effect is great. Because the effect of singly using it and massage was good, in order to developt the advantage of Traditional Chinese medicine, we would study the clinical effect of the third-shoulder points combined with massage, and scientifically evalue it, then hope to improve the clinical effect of Traditional Chinese treatment, and to provide the evidence for clinical therapy.Objective:Thought a random and controlled trail, after treating Periarthritis of shoulder joint by the third-shoulder points combined with massage, separately the third-shoulder point and massage, the each effects about clinical effect, shoulder joint pain degree and shoulder joint activity degree (abduction motion function of shoulder joint, ante flexion motion function of shoulder joint, distance of pollicis tip and the seventh-cervical, distance of middle finger tip and ear tip) would be compared.we will comprehensive evaluat their clinical effects, and hope providing a new idear and theoretical basis for the treatment of Periarthritis of shoulder joint with multi-therapies collocation.Methods:The 90 patients with periarthritis of shoulder joint were divided into three groups. It is a random, single-blind and controlled trail. The three groups separately using the third-shoulder points, massage and the third-shoulder points combined with massage. At beginning and ending, we will evalue the clinical effect, shoulder joint pain degree,the motion function classification of should-joint, and shoulder joint activity degree.(1) first group (Patients in the treatment group were treated with the third-shoulder points):①points:JIANYU, JIANLIAO, JIANQIAN;②acupuncture tool:the stainless steel pins for single use are tian-xie’s, sign:28, size:2.0, manufacturer:the limit company of acupuncture medical equipment Suzhou tian-xie;③operate:the patient site and exposed the disease shoulder, which was be routinely disinfecting. Selecting points,lefts before rights, ups before downs.way:doctor operates the skill of fast perpendicular insertion, the deep of 1～1.5cun, lift thrust Reinforcing Reducing after deQi. Needle Retaining 30min, Needling Manipulation once.(2) The second group (Patients in the treatment group were treated with massage)①relaxing jingo and promoting blood running:patient site and make the shoulder relaxant.the doctor malaxats the pain point by the finger pulp or thenar of thumb.the strength of malaxation is from soft to heavy, and remains 5min;②dredging meridian:the patient’s position was same.doctor selects JIANJING, JIANYU, JIANLIAO,JIANZHEN,TIANZONG, which was stimulated lmin;③movementing joint:the position was same.doctor make his one hand hold one hand of patient, vibrating and make abduction motion, ante flexion motion at the same time.the others put on the disease shoulder, malaxating, and movementing from soft to heavy. Dont move joint churlishly. After finishing, doctor combes pation’s muscle by foulage and kneading, fixting the shoulder and arm.④bombing and plwking the jinluo:as the patient siting, the doctor bombs and plwks thetendon of long head of biceps brachi, brachycephaly muscle, and supraspinatus tendon, by by thumb and forefinger, middle finger. The strength is from soft to heavy, in order to release the adhesive muscle.(3) The third group (the third-shoulder points combined with massage):the way of acupuncture and massage is same with above.(4) The three groups also have exercise rehabilitation, and be informed that the attention should be paid on keeping warm, avoiding cold and protecting the shoulder joint. Treatment above was be carrid on once every day. One course is ten times. The result value will be carried on after finishing two courses。Results:1. The difference that clinical effect on the third-shoulder points combined with massage, the third-shoulder points and massage had noticeable statistical significance (P<0.01), the difference that clinical effect on the third-shoulder points and massage had no statistical significance (P >0.05).2. Before the treatment, the difference that shoulder joint pain degree of each group by multiple comparing rank sum test had no statistical significance (P>0.05);After the treatment, the difference that shoulder joint pain degree on third group and others had noticeable statistical significance (P<0.01); the difference that shoulder joint pain degree on first group and second group had no statistical significance (P>0.05).3. Before the treatment, the difference that the motion function classification of should-joint by multiple comparing rank sum test had no statistical significance (P>0.05);After the treatment, the difference that the motion function classification of should-joint on third group and others had noticeable statistical significance (P<0.01); the difference that the motion function classification of should-joint on first group and second group had no statistical significance (P>0.05).4. Before the treatment, the difference that shoulder joint activity degree(abduction motion function of shoulder joint, ante flexion motion function of shoulder joint, distance of pollicis tip and the seventh-cervical, distance of middle finger tip and ear tip) by multiple comparing rank sum test had no statistical significance (P>0.05);After the treatment, the difference that shoulder joint activity degree on third group and others had noticeable statistical significance (P<0.01); the difference that shoulder joint activity degree on first group and second group had no statistical significance (P>0.05).Conclusions:1. The therapeutic efficacy of the third-shoulder points combined with massage is great significant and provids a new idear and theoretical basis for the treatment of eriarthritis of shoulder joint with multi-therapies collocation.2. The therapeutic efficacy of the third-shoulder points combined with massage is better than the methods of the third-shoulder points and massage in treating periarthritis of shoulder joint.3. The therapeutic efficacy of the third-shoulder points is no better than the method of massage in treating periarthritis of shoulder joint.更多还原